Biliary complications and efficacy after ablation of peribiliary tumors using irreversible electroporation (IRE) or radiofrequency ablation (RFA)

A Retrospective Study on Biliary Cooling During Thermal Ablation of Central Liver Tumors in Taiwan

Background: Thermal ablation of centrally located liver tumors carries an increased risk of bile duct injury due to their proximity to the biliary tree. We aim to evaluate whether biliary cooling using a nasobiliary tube can effectively mitigate bile duct injury during the ablation process. Methods: We retrospectively analyzed the data of 322 patients who underwent thermal ablation at Dalin Tzu Chi Hospital from July 2020 to June 2023 and identified those who received prophylactic biliary cooling during thermal ablation for central liver tumors. Data including demographics, tumor characteristics, procedural details, and clinical outcomes were analyzed. Results: Among the 322 patients who underwent thermal ablation, 9 with central liver tumors received prophylactic biliary cooling. The median distance between the tumor and the central bile duct was 1 mm (range: 0-4 mm), the temperature of the cold normal saline was 4 °C, and the mean volume of normal saline infused was 150 mL (range: 100-200 mL). Complete ablation was achieved in all patients in a single session without any biliary injury. One patient developed acute cholangitis after ENBD placement, which resolved with antibiotic therapy. Conclusions: Biliary cooling with 4 °C cold saline through a nasobiliary tube can improve the safety and effectiveness of thermal ablation for central liver tumors.

Nanosecond pulsed electric field ablation as first-line curative therapy for hepatocellular carcinoma in high-risk locations a prospective multicenter

BACKGROUND

Preclinical studies have shown that nanosecond pulsed electric field ablation (nsPEF) is a novel nonthermal ablation modality that can eradicate tumors near critical structures. We conducted the prospective multicenter trial to investigate the efficacy and safety of nsPEF for hepatocellular carcinoma (HCC) in high-risk locations.

MATERIALS AND METHODS

This study was conducted at five hospitals in China. Patients with HCC fulfilling the Milan criteria and located immediately adjacent to (<0.5 cm) the portal vein, hepatic vein, diaphragm, gastrointestinal tract, liver capsule, or gallbladder were enrolled. The primary endpoint was the complete ablation rate at 1 month, and adverse events. The secondary endpoints included local tumor progression (LTP), recurrence-free survival (RFS), and overall survival.

RESULTS

From March 2020 to June 2022, 192 patients were enrolled (148 males [77.1%]; median age 58.5 years [interquartile range, 51.0-66.0 years]). The median follow-up duration was 33.5 months. The technical success rate was 99.5%. Complete ablation was achieved in 91.7% of the 217 tumors. Complete ablation rates at 1 month were significantly higher in tumors <2 cm vs. ≥2 cm (90.1% vs. 71.7%, P = 0.002). The estimated 1-, 2- and 3-year cumulative incidences of LTP were 9.8%, 13.8%, and 15.7%, respectively. The maximum tumor diameter (hazard ratio [HR] = 2.62, P = 0.014) and age (HR = 0.42, P = 0.026) were independent predictive factors for LTP. The RFS rates at 1-, 2- and 3-year were 72.2%, 51.7%, and 43.5%, respectively. No periprocedural thermal damage was observed. Grade ≥3 treatment-related adverse events occurred in nine (5.6%) patients.

CONCLUSION

To our knowledge, this was the first prospective trial demonstrating that nsPEF was effective and relatively safe for HCC in high-risk locations, and may serve as an alternative therapeutic option for HCC suboptimal for thermal ablation.

Clinical and safety outcomes in unresectable, very early and early-stage hepatocellular carcinoma following Irreversible Electroporation (IRE) and Transarterial Chemoembolization (TACE): A systematic literature review and meta-analysis

BACKGROUND

Locoregional treatments for early-stage unresectable hepatocellular carcinoma (HCC) are widely used, with irreversible electroporation (IRE) and transarterial chemoembolization (TACE) representing two non-thermal treatment options. However, to date, no systematic evaluations of these technologies have been conducted. This study sought to comparatively assess the safety and effectiveness of IRE and TACE for the treatment of very early and early-stage, inoperable HCC via systematic literature reviews (SLRs) and meta-analyses.

METHODOLOGY

Searches were conducted targeting English-language publications and congress proceedings of clinical trials and observational studies from January 1, 2012 to December 21, 2023 that reported effectiveness and safety outcomes (tumor response, progression-free survival (PFS), adverse events (AE)) for IRE and TACE. Two reviewers independently assessed eligibility and abstracted data. For each procedure, meta-analyses were conducted to assess tumor response by follow-up time point, as data permitted, and other outcomes were descriptively analyzed; Quality and risk of bias assessments were performed.

RESULTS

12 IRE publications (195 patients) and 33 TACE publications (6,899 patients) met eligibility criteria. During 0 to < 3 month follow-up, complete response was achieved in 84% of IRE patients vs. 68% for TACE (all results at 1-month); a proportion that increased at 3 to < 6 months (91% IRE vs. 41% TACE). Median PFS was 10.4 months for IRE and 19-30 months for TACE. Serious AEs (SAEs) were experienced by 4% vs. 5% of IRE and TACE patients, respectively.

CONCLUSION

Both IRE and TACE are safe and effective non-thermal treatments for unresectable, very early and early-stage HCC. The high rate of short-term complete response observed for IRE, coupled with a low SAE rate, may support the broader adoption of this procedure in this patient population.

A multicenter, randomized, parallel-controlled clinical trial protocol to evaluate the safety and efficacy of irreversible electroporation compared with radiofrequency ablation for the treatment of small hepatocellular carcinoma

BACKGROUND

At present, the main clinical application of local ablation therapy, such as radiofrequency ablation (RFA), is to heat the tissue to a certain temperature. However, high temperature will cause thermal damage. Irreversible electroporation (IRE) is a novel minimally invasive local ablation technology for tumors. By high-frequency pulse, the tumor cell membrane can be irretrievably perforated, resulting in the destruction of the intracellular environment, which can preserve important structures in the treatment area. However, there are no randomized controlled clinical trials comparing the efficacy of IRE with traditional local ablation in the treatment of liver cancer.

AIMS

This study aims to conduct a randomized controlled clinical trial comparing the efficacy of IRE with RFA in the treatment of liver cancer.

METHODS

We will conduct a multicenter, randomized, parallel-controlled non-inferiority clinical trial to compare the efficacy and safety of IRE and RFA for hepatocellular carcinoma (HCC). One hundred and ninety patients with HCC from five academic medical centers will be enrolled. The patients will be randomized into treatment arm (IRE) and control arm (RFA). The primary outcome is the progress -free survival (PFS) and the key secondary outcome is the Overall survival (OS).

RESULTS

Forty-eight patients had been recruited from 5 centers, of which, 33 patients (median age, 59.1 years) with 38 tumors had completed the 1-month follow-up and 21 patients have complete the 3-month follow up, with 2.3 months median follow up period. The mean largest tumor diameter is 3.9 cm. No end point was observed for PFS or OS in both groups, and the complete ablation rate was 100% in both groups. The lesions in the IRE group showed obvious shrinkage 1 month after procedure. One major adverse event (AE) was occurred in the control group.

CONCLUSION

This is the first randomized controlled clinical trial to compare the clinical effects of IRE and RFA. The preliminary results suggest that both RFA and IRE are effective in the treatment of HCC, which can provide strong evidence for the use of IRE in HCC and provide more options for the treatment of patients with HCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials. gov, identifier NCT05451160.

The debate between electricity and heat, efficacy and safety of irreversible electroporation and radiofrequency ablation in the treatment of liver cancer: A meta-analysis

Both irreversible electroporation (IRE) and radiofrequency ablation (RFA) are viable ablation methods for localized treatment of liver tumors. We conducted a meta-analysis to access the efficacy and safety of IRE and RFA in liver cancer treatment. Clinical studies on IRE and RFA for the treatment of liver cancer were collected from PubMed and CNKI until June 2023. We screened the literature for ablation success rates at 1 month post-operation, extracting keywords such as "ablation success rate," "technical success rate," "recurrence rate," and "complication" for meta-analysis. A total of 37 articles were included: 24 related to RFA involving 1,685 cases and 13 related to IRE involving 524 cases. The results demonstrate that ablation success rates at post-operative 1 month for IRE and RFA were 86% (95% CI: 82-89%) and 87% (95% CI: 81-92%), respectively. Technical success rates were 96% (95% CI: 88-100%) and 99% (95% CI: 96-100%). In addition, the recurrence rate was 16% (95% CI: 12-22%) in RFA group and 16% (95% CI: 9-23%) in IRE group. In terms of safety, the RFA had a complication rate of 28% (95% CI: 10-50%) and the IRE had a rate of 26% (95% CI: 13-43%). In conclusion, IRE and RFA exhibit similar ablation success rates at 1 month post-operation and comparable complication rates, making them both safe and effective treatment options.

Intraductal ablation therapy for malignant biliary obstruction

BACKGROUND

Malignant biliary obstruction is usually attributed to the enlargement of tumors within or adjacent to the biliary tract, leading to blockage or compression of the bile ducts. Common causes include pancreatic head cancer, bile duct cancer, gallbladder cancer, liver cancer, and metastatic diseases. Most cases have an insidious onset, lack effective early screening methods, and 70% of patients cannot undergo surgical resection, with a 5-year survival rate of about 30%. Therefore, relieving biliary tree obstruction is crucial. Biliary stents often mitigate the obstruction but can be hindered by tumor progression, endothelial hyperplasia, and bile sludge. As a result, new treatment approaches are constantly being explored to improve outcomes for patients with malignant biliary obstruction.

CURRENT SITUATION

One promising technique that has emerged in recent years is radiofrequency ablation (RFA). This innovative method utilizes high-frequency radio waves to generate heat and selectively target tumor cells through localized heating while preserving surrounding healthy tissue. RFA aims to slow tumor growth and enhance biliary stent durability. Studies on endoscopic RFA for malignant biliary obstruction are encouraging. Integrating it with palliative care may better manage symptoms and extend patient quality of life.

CONCLUSION

In conclusion, while malignant biliary obstruction remains a complex medical challenge with limited treatment options available for some patients, ongoing research into innovative techniques like radiofrequency ablation offers hope for better outcomes in the future. It is crucial for healthcare professionals to stay informed about these advancements and continue exploring new ways to enhance patient care in this difficult clinical scenario.

Non-Operating Room Anesthesia (NORA) for Ultrasound-Guided Liver Radiofrequency Ablation

INTRODUCTION

Percutaneous ultrasound-guided radiofrequency ablation (RFA) is a well-studied treatment option for locally non-advanced hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLMs). Sedation is of crucial interest as it enables safe and pain-free procedures. Whether the type of sedation has an impact on procedural outcome is still not well investigated.

METHODS

We retrospectively collected data on patients undergoing liver RFA for various oncological conditions. Procedures were conducted in a non-operating room anesthesia (NORA) setting. Procedural-related complications and short-term oncological outcomes were analyzed.

RESULTS

Thirty-five patients (mean age 71.5 y, 80% male) were treated for HCC (26), CRLM (6) and gastric cancer metastases (3). Mean lesion size was 21 mm (SD ± 10.1 mm), and the most common tumor localization was the right hepatic lobe. RFA was performed in a step-up sedation approach, with subcutaneous lidocaine injection prior to needle placement and subsequent deep sedation during ablation. No anesthesia-related early or late complications occurred. One patient presented with pleural effusion due to a large ablation zone and was treated conservatively. Local tumor-free survival after 1 and 6 months was 100% in all cases where a curative RFA approach was intended.

CONCLUSIONS

NORA for liver RFA comes with high patient acceptance and tolerance, and optimal postoperative outcomes and oncologic results.

Thermal ablation for hepatic tumors in high-risk locations

Thermal ablative techniques such as radiofrequency and microwave ablation are minimally invasive and cost-effective approaches that are currently being adopted as alternatives to surgical resection for primary and metastatic liver malignancies. However, they are considered to be relatively contraindicated for tumors in high-risk locations due to technical difficulties and a perceived increased risk of perioperative complications. Several techniques, including artificial ascites, non-touch multibipolar ablation, and laparoscopically assisted ablation, can be used to improve the outcomes of ablation for high-risk tumors. This review aims to provide a comprehensive summary of the techniques currently used to improve thermal ablation outcomes for high-risk liver tumors.

Percutaneous transhepatic cholangial drainage/percutaneous transhepatic biliary stent implantation for treatment of extrahepatic cholangiocarcinoma with obstructive jaundice

Extrahepatic cholangiocarcinoma is a malignant tumor originating from the extrahepatic bile duct including the hilar region to the lower bile duct of the common bile duct. With the development of interventional techniques and medical materials, percutaneous transhepatic cholangial drainage (PTCD) or percutaneous transhepatic biliary stent implantation (PTBS) has become the main treatment to relieve biliary obstruction. However, the occurrence of postoperative complications seriously affects the prognosis of patients, and the combination of biliary stenting with local treatment has been found to significantly prolong the time to biliary patency. This article reviews the progress of PTCD/PTBS in the treatment of extrahepatic cholangiocarcinoma with obstructive jaundice, evaluates its clinical efficacy, and points out the current problems and posible solutions to provide more reference for subsequent related studies.

Prevention of major biliary complications by fusion imaging for thermal ablation of malignant liver tumors adjacent to the bile ducts: a preliminary comparative study

PURPOSE

Ultrasound (US)-guided thermal ablation (TA) may cause major biliary complications, particularly in patients with malignant liver tumors (MLTs) adjacent to the bile ducts. Fusion imaging (FI), is postulated to reduce complication rate; however, there is a lack of clinical data to support this theory. Thus, the aim of our study was to evaluate the safety and efficacy of FI for TA of MLTs proximal to the bile ducts.

METHODS

A retrospective single-center review was conducted on a total of 289 patients with 316 MLTs adjacent to the bile ducts. The patients were divided into two groups based on whether FI was used in the ablation procedures. The choice of the FI-assisted procedure always depends on different operation periods and whether registrations will succeed. The baseline demographics and outcomes of these patients were compared. The efficacy was determined at the 1-month follow-up using contrast-enhanced computed tomography/magnetic resonance. Biliary complications and local tumor progression were subsequently followed-up every 3-6 months. The last follow-up visit was before August 30, 2019.

RESULTS

Among the included tumors, the incidence rate of major biliary complications after ablation in the FI group was 1.6%, which was significantly lower than that in the non-FI group (7.9%, p = 0.005). There was no significant difference in the efficacy rates of the techniques [99.5% (185/186) versus 98.4% (123/125), p = 0.56] or local progression rates [3.8% (7/185) versus 5.7% (7/123), p = 0.61] between the FI and non-FI groups.

CONCLUSION

FI for US-guided TA could be a noninvasive means to decrease major biliary complications. Trial registration number and date of registration: retrospectively registered.